Douglas S. Snyder

Safety of Direct Laryngoscopy As an Outpatient Procedure

The safety of outpatient direct laryngoscopy has recently been challenged in the literature. We reviewed the first 589 direct laryngoscopies performed at a new outpatient surgery center. There were nine unplanned admissions to the hospital, including five airway emergencies that developed within the first 30 min after extubation. Three patients required reintubation before leaving the operating room. On postoperative telephone follow‐up, 9% complained of mild to moderate sore throat. There were no major complications after discharge. We conclude that the risk of airway emergencies after direct laryngoscopy is less than 1% in carefully selected patients. The procedure can be safely performed as an outpatient procedure as long as transportation to a hospital is readily available for the few patients in whom complications arise.

Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery.

STUDY OBJECTIVE To determine if remifentanil would offer a superior hemodynamic and recovery profile compared to the current standard of care, which implements a fentanyl-based technique. DESIGN Randomized, single-blind study. SETTING Outpatient center associated with tertiary care center. PATIENTS 75 outpatients undergoing microsuspension laryngoscopy. INTERVENTIONS Patients were randomized to either a remifentanil induction (0.5 microg/kg/min) and maintenance (0.25 microg/kg/min) versus fentanyl (maximum of 250 microg) as the only opioid. All patients received propofol as part of the induction and maintenance with or without the use of nitrous oxide. MEASUREMENTS Assessment of hemodynamics [heart rate (HR) and blood pressure(BP)], presence of perioperative myocardial ischemia on ambulatory electrocardiographic monitoring, and time to discharge. MAIN RESULTS Significantly fewer patients in the remifentanil group demonstrated episodes of tachycardia (HR > 100 beats per min) compared to the fentanyl group (14% vs. 40%, p<0.05), with significantly fewer episodes of tachycardia and hypertension per patient. Recovery profiles between the two groups did not show clinically significant differences. CONCLUSIONS Remifentanil, a new short-acting opioid, offers excellent hemodynamic control for brief, intense outpatient procedures performed in high-risk patients; however, its use was not associated with any improvement in recovery profiles.

Effects of pentobarbital on inotropic state of isolated canine left ventricle.

SummaryAlthough pentobarbital has been found to depress myocardial function, the magnitude of its direct effects on ventricular contraction at anesthetic concentrations has not been well quantified. The direct effects of pentobarbital on left ventricular function were measured by employing an isolated canine heart preparation with a blood oxygenator. Seven hearts were perfused with blood, dextran, and perfluorochemical artificial blood. Ventricular function was evaluated using the slope of the end-systolic pressure-volume relationship (Ees) and the maximal rate of pressure development (dP/dtmax) in ventricles contracting isovolumically in control, after a low dose (13 µg/ml), and after a high dose (48 µg/ml) of pentobarbital. These concentrations represent one-half and two times the typical value (25 µg/ml) found to produce anesthesia in canines (assessed by tail clamp or blink reflex). The low dose of pentobarbital did not produce clear-cut depression in contractile function. The high dose of pentobarbital produced significant reductions of Ees, and dP/dtmax:Ees decreased 29%, from a control of 4.30 ± 0.84 to 3.05 ± 0.49 mmHg/ml and dP/dtmax decreased 24%, from a control of 909 ± 148 to 695 ± 173 mmHg/s. Thus, the threshold for the direct depressant effect of pentobarbital on ventricular function falls within the range of half to double the typically-reported anesthetic concentrations.

Management for electroconvulsive therapy of a patient with inoperable coronary artery disease and ankylosing spondylitis

A 69-year-old male with severe coronary artery disease, ankylosing spondylitis, and severe major depression was scheduled for electroconvulsive therapy (ECT). The patient had previously failed or proved intolerant of antidepressant drug therapy. The nature and severity of the patients diseases and complexity of potential interactions with ECT and anesthesia required sequential assessment of hemodynamic and airway tolerances with successive treatments. Despite substantial risks for particular patients, ECT may provide the only treatment option for life-threatening psychiatric illness and warrants innovative approaches to anesthetic management.